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BULL E� MENT SEp 10 2024
VIL E OF RYE OK
938 KIN ET RYE B ,NY 10573 I VfLLAGE OF RYE BROOK
BUI!_DiiJG DEPARTMENT
ov
PLUMBING PERMT APPLICATION
FOR OFFICE USE ONLY BP#: PP#:
Approval Date: Permit Fee: $
Approval Signature: Disapproved:
(fees are non-refundable)
DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY THE BUILDING
INSPECTOR.THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A
PERMIT IS 12%OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00
Application dated, — 0—5) is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of
a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this
document agree that said plumbing work
�wiII be in conformance with all applicable Federal,State,County and Local Codes.
1.Address: 1/1�1�"1��`'' SBL: — li 0 Zone:)10046
A.
2.Proposed Work:
3.Property Owner: Address: jq VjW
Phone#: >h - l y 1 Cell#: email: MA tb elow
4.Master Plumber: Address: D
_ 6
Lic.#: Phone#: Cell#: email: at-_1 a
yvv
Company Name: �6 Address: 8 j CA
1)4
INDICATE FIXTURES&LINES TO BE INSTALLED AS PER THE FOLLOWING SCHE LE:
Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total
Closets Fountains Tubs Tubs Service Service Sewer LP Gas
Basement
1st Floor
2nd Floor
3'd Floor
4's Floor
5a'Floor
Exterior
5.*List Other Equipment/Provide Details: 1 SSW-e +—Sf can, eV4 VP-
(Notarized Signatures Required Next 2 Pages)
- 6/v202a
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
being duly sworn,deposes and states that he/she is the applicant above named,
(print name of individual signing as the applicant)
and further states that(s)he is the Master Plumber for the legal owner and is duly authorized to make and file this application.
That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use
conducted at the above captioned property will be in conformance with the details as set forth and contained in this application
and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire
Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations.
Sworn to before me this '"t Sworn to before me this Q
day of ,20 D A day of `� 20 o�y
Signature Af Property caner Signature of plic t
1q; 6W 14
Print Name of Property Owner Print a of Applicant
AL-X
N Public Nota
Amanda 9;ucci '
Amanda $ucci Notary Public•Conriecticvt
Notary Pt►blic-Connecticut My Commission.Expires
My Commission Exp+r@s Februery28.2025
F bruary 28,2C25
e properly completed in its entirety and roust include the notarized sigitature(s) of
the legal owner(s)of the subject property, and the applicant of record in the spaces provided. Applications
not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be
returned to the applicant.
-2-
btl/2o2a
BUIL^RYE
ENT D E C E O v E
VILOK S E P 10 2024
938 KINGNY 10573
4 -0
VILLAGE OF RYE BROOK
w ov Pr It!
AFFIDAVIT OF COMPLIANCE
VILLAGE CODE U16 • STORM SEWERS AND SANITARY SEWERS
THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED
ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT
APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT .
STATE OF NEW YORKK, COUNTY OF WESTCHESTER ) as:
3, UMte, G0 kAA , residing at, PVj� `
(Print name) 1 (Address where you live)
being duly sworn, deposes and states that(s)he is the applicant above named, and further states that(s)he is the
legal owner of the property to which this Affidavit of Compliance pertains at;
,p Ki flA 0 S,(- CMG ytf� , Rye Brook,NY.
(Job Address)
Further that all statements contained herein are true, and that to the best of his/her knowledge and belief, that
there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer, and further
that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources
of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State,
County and Village Codes.
1-�4
(Signature of Prope4 Owner(s))
(Print Name of LL
Property Owner(s))
Sworn to before me this
day of 20 `emu
Amanda Succi
Notary Public-Connecticut
My romrnisslon Expires
FebTusry 28..2025
-3-
6/1/2024
QyE BRC�v�,
1932 BUILDING DEPARTMENT
❑BUILDING INSPECTOR
OASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK
❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573
(914) 939-0668 FAx (914) 939-5801
www.ryebrook.org
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
ADDRESS : DATE: l
PERMIT# ISSUED: SECT: BLOCK: LOT:
LOCATION: OCCUPANCY:
❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/ REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION
❑ NATURAL GAS
❑ L.P. GAS 1 ` ✓e
❑ FUEL TANK �� J
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
❑ CROSS CONNECTION
❑ FINAL
❑ OTHER
41
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